Please fill out the application below to be an AC Groups participant. Your responses to these questions will help as we try and place you in an group of people from similar backgrounds "*" indicates required fields Email* Phone*Name* Age* Gender* Male Female Others Others Gender Location (city, state)* Occupation* Employer, if applicable Highest level of EducationHigh SchoolBachelor's degreeMaster's degreeDoctoral degree (MD, PhD, PsyD, etc.)OtherSchool attended (location - city and state) Relationship status Single In a committed relationship Married Other If others, please specific your relationship status If you are a parent, please select an age range for your child or children Baby: 0-12 months Toddler: 1-3 years Preschool: 3-5 years Gradeschool: 5-12 years Middle School: 12-15 High School: 15-18 Young adult: 18-21 years Adult Other: Please mention Why AC Groups?Why are you interested in joining an Authentic Connections Group?* Are there any topics that you are most interested in connecting with other group members about? (for example, physicians, counselors or other health care providers; relationship difficulties or separation, new motherhood, single fatherhood, parenting tweens/ teens, bereavement, workplace stress, professional burnout, retirement, LGBTQ+, and other topics) For those who can't afford the full price of $100 per group, we offer a sliding scale fee. If you are in need of a reduced sliding scale fee in order to be able to participate in AC Groups, please check the box below.* YES, I would like to request a sliding scale fee to participate in AC Groups NO, I would NOT like to request a sliding scale fee and am comfortable with the suggested donation of $100 per weekly group session. N/A, I am registering through an organization that is responsible for any payments If requesting a sliding scale fee, please indicate a dollar amount per group that would make AC Groups participation feasible. How did you hear about us?* Scheduling informationThis section of the survey asks about your availability so that our team can place you in a groupTime Zone* Eastern Central Mountain Pacific Other Please, Mention Your Time Zone Please check all times you are available or that may work (assuming a few weeks' notice) to attend weekly, one-hour groups:MORNINGS Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 08:00 AM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 09:00 AM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 10:00 AM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 11:00 AM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday AFTERNOONS Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 12:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 01:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 02:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 03:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 04:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday EVENINGS Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 05:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 06:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 07:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday 08:00 PM Mondays Tuesdays Wednesdays Thursdays Fridays Saturday NONE Mondays Tuesdays Wednesdays Thursdays Fridays Saturday Is there anything else that you would like us to know?
